L-carnitine and acetyl-L-carnitine combined for prevention and treatment of syndromes related to diseases of energy metabolism

ABSTRACT

A combination can be of L-carnitine and acetyl-L-carnitine administered orally or as parenteral injection in domesticated animals, especially pet animals, and humans for prevention or treatment of syndromes or diseases arising from dysfunctional energy metabolism. Syndromes involving skeletal and cardiac muscle benefited from L-carnitine, syndromes related to the central nervous system improved with acetyl-L-carnitine. Although the two cofactors do not substitute metabolically for each other effects of the combination are found to be synergistic.

BACKGROUND OF THE INVENTION

The present invention relates to dysfunctional energy metabolism of bothglucose and lipids in animals and humans. More particularly, a novelcombination of metabolic cofactors, L-carnitine combined withacetyl-L-carnitine, restores normal mental and physical activity to agedpatients with dysfunctional energy metabolism and, when employedprophylactically, prevents development of related syndromes.

In the normal course of aging an organism's ability to synthesize,conserve, and absorb crucial metabolic cofactors declines. Conversion ofnutrients to useful energy within cells involves highly specificenzymatic processes which are sensitive to presence or absence of thesecofactors. In the higher order of animals, especially with respect tohumans, as well as laboratory rodents, enzyme pathways of energymetabolism are known with relative precision. Despite extensive researchefforts, however, interrelationship of many metabolic processes andenzymatic cofactors remain imprecisely known. Indeed, metabolicinterrelationships of enzymatic cofactors L-carnitine andacetyl-L-carnitine in cardiac and skeletal muscle have not beencompletely defined. The same is true in nervous tissue, especially thebrain, where available research data concerning function of thesecofactors are often contradictory and inconclusive owing to theinordinate difficulty in establishing truly controlled experimentalformats. Much of what is known has been gained from the organ's responseto traumatic, toxic, and ischemic insults as well as investigations ofthese cofactors' effects in chronically diseased brains. Suchinformation provides little or no guidance to those concerned withpsychophysiologic and psychomotor disturbances or confronting syndromesaffecting multiple tissues. The following brief notations are believedto illustrate the complexity of the state of the art knowledge ofdiseases of energy metabolism.

The study of disease of energy metabolism commonly referred to asmitochondrial diseases is an emerging specialty in human medicine. Mostof these diseases arise from mutation of the mitochondrial genomes and,to a lesser extent, nuclear genes. Such mutations result in specificdysfunctional enzymes in metabolic pathways and in structural changes ofmitochondria which disrupt enzyme orientation in metabolic pathwaysthereby impairing their efficiency. Mitochondrial genome mutations mayexist at birth but typically occur over time as base dilutions,substitutions, and insertions during the course of replication; or inresponse to environmental factors, disease, and accumulation of toxicmetabolites. Clinical syndromes presented depend upon the metabolicpathway affected and the proportion of dysfunctional mitochondria thathas been attained. Organs normally effected by disease of energymetabolism are highly differentiated, nonregenerating tissues requiringhigh levels of oxygen and energy, such as brain and skeletal and heartmuscle. Treatment of these diseases is directed to sustaining life bysupplementing high levels of metabolic cofactors in an effort to skewmetabolism along specific pathways and to providing substrates for thepathways. Rarely, in human medicine, do deficiencies of cofactors orsubstrates cause diseases of energy metabolism. In veterinary medicineonly a few genetically based diseases of energy metabolism arerecognized. Among them are dilated cardiomyopathy in dogs and stresssyndrome in swine. However, deficiencies of metabolic cofactors in dogshave been investigated. A study of commonly encountered age-relatedsyndromes in old dogs, examples of which are included in thisapplication, revealed them to be due to dysfunctional energy metabolism.More specially, syndromes involving heart and skeletal muscle wererelieved by L-carnitine supplemention while a syndrome affecting thebrain was relieved by increased acetyl-L-carnitine intake. However,complex interrelationships exist. For example, a treatment for apsychotic syndrome with acetyl-L-carnitine was successful but resultedin emergence of a heart failure syndrome and both cofactors wererequired to normalize the dog. In another case, synergistic effects wererealized with the two cofactors combined as opposed to their individualuse in treating a syndrome involving skeletal muscle. And, in yetanother case, a dog that heretofore had required heavy sedation tocontrol an epileptic syndrome, experienced unexpected improvement inafter it had been treated with combined L-carnitine andacetyl-L-carnitine for several weeks.

L-carnitine as well as acetyl-L-carnitine are natural constituents ofhigher organisms, particularly animal heart and muscle tissue and can besynthesized by the body or obtained from red meat, poultry, fish, anddietary products. L-carnitine is absorbed from the small intestine intosystemic circulation at a rate of about 2 to 5 mg per pound body weightwhich is compatible with normal physiologic function and the basis fordosages in the accompanying studies. In standard medical treatment ofsyndromes related to deficiency of L-carnitine or L-carnitine-dependentenzymes dosage of L-carnitine employed may be 10 to 50 times higher thanrate of physiologic intestinal absorption. This affords passivediffusion of carnitine into systemic circulation but such high dosageshave the risk of causing diarrhea.

L-carnitine (3-hypodroxy-4-N-trimethylaminobutyric acid) has two mainfunctions, both critical to energy metabolism. The first istranslocation of long-chain fatty acids from the cytosol across theouter and inner mitochondrial membranes and intervening space into themitochondrial matrix. The second function is to modulate intracellularCoA homeostasis within the mitochondrial matrix by transesterifation ofacyl-CoA esters produced in B-oxidation which regenerates CoA andacylcarnitine. Accumulation of long chain acyl-CoA esters is aconsequence of enzyme disfunction and metabolic impairment or stasis inthe B-oxidation system. Resulting shortage of available CoA then limitstransfer of acetyl groups to the Krebs cycle for energy production.Acylcarnitine, produced during homeostasis, can be exchanged across themitochondrial membrane for free carnitine and eventually transported outof the cell to be excreted in urine. Canids are unique in the fact thattheir liver and kidneys synthesize carnitine but they lack an enzyme inskeletal and cardiac muscle which is crucial to the last stage ofL-carnitine synthesis. In dogs L-carnitine is synthesized in the liverand transported to muscle tissue.

Acetyl-L-carnitine (-trimethyl-B-acetylbutyrobetaine) sharesintracellular CoA homeostatic function with carnitine. It is theprevalent ester of carnitine in tissue, freely exchangeable acrosssubcellular membranes, and can serve as a pool of acetyl groups toregenerate acetyl-CoA. This property comes into play in instances ofexcessive exercise where glycolysis has resulted in accumulation oflactic acid in muscle cells. Studies with rat brain tissue showacetyl-L-carnitine to be associated with increased glycolysis and oxygenmetabolism. Other studies indicate acetyl-L-carnitine enhancesketone-body metabolism in rat brains. In experimentation with ratsacetyl-L-carnitine has been shown to maximize energy production, promotemembrane stability, restore membrane changes that are age-related, andserve as precursor to acetylcholine. Cholinergic effects enhance nerveimpulse transmission and have been demonstrated to counter or delayage-changes and dementia in brains of rodents and humans.

In addition to depleted available energy and concomitant depression ofcell and organ function another consequence of impaired energymetabolism is formation of free oxygen radicals and their destructiveeffects on proteins and other large molecules, mitochondrial membranes,and especially mitochondrial DNA. Environmental sources of free radicalsare infection, drugs, hypoxia, chemicals, and food. These destructiveeffects are cumulative leading to development of physiologicdysfunctions with increasing age, and along with mitochondrial genomemutation from other causes, must be considered as contributors to theetiology of syndromes seen with the dogs in this report. Normally, celland organ function deteriorates with age resulting in reducedbiosynthesis of metabolites and cofactors, reduced digestive functionand enteral absorption, and impaired renal tubule resorption fromglomerular filtrate. In elderly dogs any or all of the above can lead todepletion of tissue reserves of L-carnitine and acetyl-L-carnitine tothe extent that energy metabolism is impaired.

Four syndromes, psychosis, skeletal muscle weakness and atrophy,epileptiform convulsions, and cardiomyopathy were observed in dogs inthis study. Syndromes presented as singular entities as in the skeletalmuscle syndrome or as complex of syndromes. Psychosis, in the form ofextreme anxiety with trembling, hiding and panicky flight are common inold dogs exposed to sharp noises such as fireworks discharges. Even amild stimulant such as the sound of cellophane being crumbed into a ballwill illicit a panic response in some dogs. Management of most suchcases is with tranquilizers during periods when stimuli are mostprevalent (e.g. New Years Eve and The Fourth of July). Tranquilizers donothing to cure the patient, their effect is psychological depression.When patients become extremely debilitated by the psychosis moodaltering drugs such as doxepin and fluoxetine can be employed. Hereagain a cure will not be forth coming. At best the animal will be soheavily sedated as to not pose a threat to itself, property, or thepublic. Pharmacologically-active mind-depressions do not correct anymetabolic imbalances in the brain, hence do not effect a cure. In somecases psychotic episodes progress to grand mal seizures. Depressantdrugs are the common means employed for their control. Phenobarbital,primidone, and/or KBr are consumed once to several times a day. Thedrugs do not correct the underlying metabolic dysfunction in the brainbut they do stop the seizures at the expense of greatly depressing thepatient. Psychotic and seizuring dogs are not demented in the sense thatthere is large-seal neuronal dysfunction with loss of inelegance,memory, or awareness of surroundings. Psychoses are almost the opposite,with heightened awareness of sounds and events in the environment. Theymay precipitate seizures.

Among the causes of skeletal muscle weakness and reduction of mass arenutritional deficiency, in particular deficiency of SE and vitamin E. Incases of nutritional myopathy, refined to as white muscle disease, thevitamin E interrelates metabolically with SE and can be a valuableadjust to therapy. This condition is common to herbivorous andomnivorous but not carnivorous. A myopathy common in dogs is denervationmyopathy, a condition that develops secondary to herniation ofintervertebral dises and ankylosing spondyloarthropathy. Where spinalnerves are damaged reduced impulse stimulation to the innervated muscleleads to weakness, degeneration, and atrophy. This form of muscledisease is managed by attempting to reduce trauma to the spinal nerve bycontrolling chronic inflammation and bone formation along the nerve'scourse from the spine with drugs classified as non-steroidalanti-inflammatory agents. If skeletal muscle is not exercised it willbecome weak and degenerate and eventually atrophy. This condition,common to traumatic injuries, precludes normal function after extendedperiods of time. There are auto-immune myopathies where the bodyproduces an immune reaction, usually to some infectious agent, thatcross reacts with skeletal muscle. Management of these conditions isbased upon suppression of the immune reaction for an undetermined periodof time. Eventually, the reaction subsides and the immune depressantdrugs can be with drawn. There are other causes of skeletal muscleweakness and atrophy. Clinically they are morphologically similar to oneand other and require biopsy for definitive diagnosis.

Heart failure secondary to dilated cardiomyopathy has been treated withhigh dosages of L-carnitine, 100 mg per pound body weight. Such massivetherapy is only moderately successful, at best. In most cases prognosisis very guarded. One reason for the poor response may be that diagnosisis not forthcoming until pathology is so advanced it cannot be reversed.Another consideration is that L-carnitine therapy only addresses lipidmetabolism in the heart ignoring the part glycolysis may contribute.Cardiac arrhythmias are part of heart failure and evidence of pathologyof heart muscle. Arrhythmias are treated with pharmachologically activedrugs which may stabilize the heart. Drugs such as lidocaine,propanalol, digoxin, and procainamide all are useful in stabilizing theheart beat which may be critical at times but such drugs do not addressthe metabolic disturbance that caused the pathology. It is common fordogs with cardiac arrhythmias to die suddenly or, at best, be forced toremain on medication for extended periods, even for life.

As a consequence of above-noted complexities in identifying and treatingsyndromes related to dysfunctional energy metabolism as well asunderstanding their interrelationships little progress has been achievedin prevention and therapy. The following examples of U.S. Patentsrelating to carnitine and acetyl-L-carnitine are illustrative of theexisting state of the art.

U.S. Pat. No. 4,346,107 relates specifically to the use of acylcarnitinein treating dementia of human patients particularly when mentaldysfunction is related to impaired cerebral blood flow. Typifyingnumerous approaches to management of dementias, is does not investigatepsychoses and epileptiform seizures as being associated with deficits ofenergy metabolism, their connection with deficiencies of L-carnitine andacetyl-1-carnitine, the possibility of precipitating other energydeficit syndromes as a consequence of therapy with a single metaboliccofactor, and the need for therapy that modulates both glycolyses andlipid metabolism.

U.S. Pat. No. 4,599,232 relates to combination of carnitine oracetylcarnitine and coenzye Q10 for tissue metabolic disorders involvingcirculatory function. The patent's use of coenzymes Q10 directs itseffects towards control of free radical excess and facilitation ofoxidative phosphorylation, the final stage of energy metabolism. It doesnot address the observed synergistic effects of combined L-carnitine andacetyl-L-carnitine on glycolysis and lipid metabolism nor does itrecognize the need of both metabolic cofactors when treatingdysfunctional energy metabolism related to deficit of L-carnitine oracetyl-L-carnitine as discovered in the present patent.

U.S. Pat. No. 5,576,384 relates to the general use of acylcarnitine fortherapy of patients with Acylcarnitine Metabolic Dysfunction Syndrome.It excludes consideration of carnitine metabolism disorders and thecombined therapy for disorders where both deficiencies may exist.

Following are references pertaining to diseases of energy metabolismtheir causes and treatments.

Luft, R. The development of mitochondrial medicine. Proc. Natl. Acad.Sci. USA 1994; 91:8731-8738

Singh P J, Santella R N, Zawada E T. Mitochondrial Genome mutations andkidney disease. Am. Jour. of Kid. Dis. 1996; 28: 140-146

Shishido F, Uemura K, Inugami A, Tomura N, Higano S, Fujita H, Sasaki H,Kanno I, Mura Kami M, Watahiki Y, Nagata K. Cerebral oxygen and glucosemetabolism and blood flow in mitochondrial encephalopathy: a PET study.Neurorad. 1996; 38: 102-107

Pons R, DeVito DC. Primary and secondary carnitine deficiency syndromes.Jour. Child Neuro. 1995; 10: 258-2524

Castorina M, Ferraris L. Acetyl-Carnitine affects aged brain receptorialsystem in rodents. Life Sci. 1994; 54: 1205-1214

Carta A, Calvani M, Bravi D, NiBhuach alla S. Acetyl-L-Carnitine andAlzeimer's disease: pharmacological considerations beyond thecholinergic sphere. N.Y. A cad. of Sci. 324-326

Aureli T, Miccheli A, Ricciolini R, DiCocco ME, Ramacci MT, Angelucci L,Ghirardi O, Cont F. Aging brain: effect of Acetyl-L-Carnitine treatmenton rat brain energy and phospholipid metabolism. A study by 31P and`HNMR spectroscopy. Brain Res. 1990; 526: 108-112

Stanley C. Carnitine disorders. Adv. in Ped. 1995; 42: 209-242

Shoubridge E A. Mitochondrial DNA disease: Histological and cellularstudies. Jour Bioenerg. and Biomemb. 1994; 28: 301-310

Zeviani M, Amati P, Savoia A. Mitochondrial Myopathies. Curr. Opin.Rheum. 1994; 6: 559-567

Sisson D D, Thomas W P. Myocardial diseases. In: Ettingen S J, Feldman EC, ed. Textbook of Veterinary Internal Medicine. 4th ed. Philadelphia: WB Saunders, 1995: 995-1005

BRIEF SUMMARY OF THE INVENTION

The present invention, A novel combination of L-carnitine andacetyl-L-carnitine, has been discovered to relieve syndromes related tomutations of mitochondrial genomes and age-related impairment of energymetabolism due deficiencies of L-carnitine and acetyl-L-carnitine indomesticated animals.

The invention in its various forms are easy to prepare. Liquids for oraluse are prepared at room temperature by dissolving prescribed quantitiesof crystalline forms of the cofactors in water, adding preservative andcoloring and/or flavoring, filter sterilizing, and bottling. Liquid forinjection is prepared at room temperature by dissolving prescribedamounts of each cofactor in water. If the material is to be dispensed ina multi-dose vial, preservative is added before the pH is adjusted withNaOH to neutrality and the solution is filter sterilized and bottled.Dry forms of the invention are prepared by mixing prescribed amounts ofthe two desiccated cofactors. If the invention is to be encapsulated, ananticaking agent to facilitate production may be added prior toencapsulation. If the dry preparation is to be dissolved for intravenousinjection the desecrated powder or crystalline mixture is measured intoglass vials, sealed and sterilized.

Specific quantities of L-carnitine and acetyl-L-carnitine provided inthe aqueous solutions of the invention may be varied depending uponprojected use. As an example, it is within the comprehension of theinvention that solutions may be prepared to allow each milliliterthereof to contain: from about 0.1 to 400 milligrams L-carnitine and 0.1to 400 milligrams acetyl-L-carnitine. Similarly, ratios of carnitine toAlcar in powdered forms can be varied from 1 to 100 depending uponintended usages.

All preparations of the invention are easy, safe and convenient to use.The liquid for oral consumption can be taken directly into the mouth andswallowed or measured into it with a spoon, dropper, syringe, or likedevice. Similarly, the liquid preparation can be measured into food ordrink for consumption. The usual, standardized techniques for parenteralinjection of drug with hypodermic needle and syringe is to be employedfor administering the injectable format of the invention subcutaneously,intramuscularly, intravenously, or as an additive to compatible liquidmedicaments designed for intravenous injection.

Among the preferred forms of the invention is a solution formulated tocontain 45mg L-carnitine and 45 mg acetyl-L-carnitine per milliliter.Such a preferred solution is particularly useful for oral administrationat a dosage level to provide from about 2 to 4 milligrams of eachcofactor per pound of body weight. The invention is beneficial inaleaveating symptoms when added to the food of psychotic domesticatedanimals, those with cardiomyopathy or skeletal muscle weakness oratrophy, those with tendency to have epileptiform seizures or in agedobese or debilitated animals when these conditions are due to inadequacyof available L-carnitine and/or acetyl-L-carnitine. This preferred formof the invention is particularly useful for supplementing the diet at arate of about 5 milligram per pound of body weight on a daily basis toprevent development of such as cardiomyopathy, skeletal muscle weaknessor atrophy, psychosis, some forms of epilepsy, and to generally improvemental and physical activity and well-being.

The purpose of the invention is to treat or prevent from developingdisease syndromes related to inadequate tissue levels of L-carnitineand/or acetyl-L-carnitine and to treat or prevent disease syndromesrelated to mutations of mitochondrial DNA, changes in mitochondrialstructure, and deterioration of the body's ability to synthesize,conserve, and absorb L-carnitine and acetyl-L-carnitine. One severelypsychotic dog had been unsuccessfully treated for about one year withtwo different mood-altering drugs commonly used for treatment of suchmental derangements. The owner, committed to euthanasia, agreed to afinal effort to save the animal; the novel and untested use ofacetyl-L-carnitine to treat psychosis. Response was prompt, recoverybegan in two days. The effects of acetyl-carnitine on brain functionappeared to correct the dog's psychosis. But when the dog became normalmentally, acute circulatory failure developed. L-carnitine wassubstituted for acetyl-L-carnitine and the circulatory failure wasresolved. Shortly, however, the psychosis resumed. L-carnitine andacetyl-L-carnitine were not metabolically interchangeable in this case.A novel, treatment was initiated. L-carnitine and acetyl-L-carnitinewere combined and administered in the dog's food, 5 mg per pound bodyweight. He promptly became normal and remained, so receiving dailysupplementation with the invention. This case demonstrated that, withdiseases of energy metabolism, some syndromes may be subclinical only tobe expressed in time or when a more prominent syndrome is relieved,increased activity may bring an underlying syndrome to light. Or, whentreating a syndrome with one cofactor, in this case acetyl-L-carnitine,a disturbance in metabolism may develop in another organ necessitatingthe other cofactor, L-carnitine. It is clear that when treating diseasesof energy metabolism in old dogs combined L-carnitine andacetyl-L-carnitine are in order.

This principle was underscored by a dog treated with L-carnitine forskeletal muscle atrophy, weakness and pain. It responded, functioningnormally in three weeks. Then acetyl-L-carnitine was substituted forL-carnitine to observe any cross-effectiveness. No cross-effect wasobserved. Shortly, symptoms of muscle weakness and pain resumed. Thecofactors were mixed, as in the powdered preparation of the invention,and added to the dog's food, 5 mg per pound body weight. Within one weekshe was normal. This accelerated response compared with the time ofresponse when treatment was with L-carnitine alone would suggestmetabolic synergism exists between L-carnitine and acetyl-L-carnitine.

A third case demonstrated effectiveness of combined L-carnitine andacetyl-1-carnitine for treating skeletal muscle weakness and neurologicsymptoms. Both syndromes had been long standing in an old dog that waspresented with acute circulatory failure. The dog's heart disease wasdiagnosed as being early cardiomyopathy without marked enlargement. Whentreated with procainamide and the invention at a rate of 5 mg ofcombined 1-carnitine and acetyl-L-carnitine per pound of body weight theinitial arrhythmia was converted over night. After one week theprocainamide therapy was stopped the heart continued to improve as thedog received the invention on a daily basis and within a month theelectrocardiogram was normal. This was an unprecedented response, formost such cases die within a few days. It is assumed the invention wasinstrumental in correcting the metabolic imbalance causing thecardiomyopathy.

L-carnitine and acetyl-L-carnitine are biochemically interchangeable inmitochondria through action of the enzyme carnitine acetyl-transferase.However, evidence in the studies reported herein indicate distinctdifferences in metabolic function of the two cofactors with no apparentcross reaction or substitution between them. It is well accepted thatL-carnitine effects are primarily on energy metabolism of lipids.However, metabolic pathways involving acetyl-L-carnitine are not welldefined. The following may explain how the psychotic dog was benefitted:Research indicates acetyl-L-carnitine enhances glycolysis, oxygenmetabolism and energy production in the brain. Which may partiallyexplain beneficial effects observed. Studies of humans with amitochondrial disease, MELAS, suggest symptoms and lesions are theresult of lactic acid accumulation in the brain with concomitant brainedema. Stressful events lead to increase demand for energy in the brainbut with limited reserves of acetyl-L-carnitine glycolysis is impededand lactic acid accumulates. To measurably increase glycolysis,acetyl-L-carnitine facilitate metabolism of pyruvate, making more energyavailable for cell function and limiting accumulation of lactic acidwith its detrimental effects. This same mechanism, acetyl-L-carnitinefacilitated pyruvate metabolism, explains the synergism elicited byL-carnitine and acetyl-L-carnitine, the invention was used to treat dogswith skeletal muscle weakness and pathology. Treatment of cardiomyopathywith the invention at physiological levels, mg per pound body weight,more successful than when L-carnitine alone is given even at dosages 20times higher. Although L-carnitine dependant lipid metabolism is themajor energy source in muscle, acetyl-L-carnitine dependant glycolysisis essential to normal muscle cell function.

The invention was superior to conventional therapy for treating thefollowing syndromes that arose from disturbances of energy metabolism:

Psychotic behavior was eliminated and the affected dog regained demeanorand activity level similar to three years previously while its diet wassupplemented daily with mg of the invention per pound body weight. Itshowed no evidence of depression or sedation associated withconventional therapy.

Similarly, a dog with long standing epileptiform seizures, controlled byheavy dosages of KBr had only one mild seizure a month during dietsupplementing with the invention at mg per pound of body weight daily.Without KBr therapy.

Two dogs with profound skeletal muscle weakness became fully activewhile receiving diet supplemention with mg of the invention per pound ofbody weight each day. One dog regained the ability to jump into a pickuptruck. This patient had a previously-undescribed myopathy diagnosed froma biopsy as a degenerative condition probably related to dysfunctionalenergy metabolism. Other more traditional therapies for treating themyopathy were ineffective. The other dog was able to run freely andchase cats, previous to treatment it had to be supported with a slingunder its belly when walking more than a few feet.

Two dogs with circulatory failure recovered completely during the courseof daily diet supplementation with mg of the invention per pound of bodyweight. The dogs had a brief course of oral treatment with procianamide.The superiority of invention was manifested in the completeness ofrecovery without prolonged anti-arrhythmia therapy.

Other aspects and advantages of the present invention will be apparentupon consideration of the following detailed description thereof.

DETAILED DESCRIPTION OF THE INVENTION

The term "cofactor" in general refers to carnitine, Alcar, othervitamins, and trace minerals that facilitate chemical reactions withspecific enzymes in cells. "Parenteral" shall mean any administrativemode other than oral and shall include subcutaneous, intramuscular andintravenous injection. "Syndrome" is a set of symptoms, or complex ofsymptoms occurring together which may or may not characterize a specificdisease entity. "Carnitine and Alcar responsive syndrome" shallrepresent a symptom complex which is benefited by amelioration ofsymptoms toward the normal through treatment of the patient withcarnitine and acetyl-L-carnitine.

The purpose of the invention is to treat, or prevent from developing,disease syndromes related to inadequate tissue levels of one or bothmetabolic cofactors, and to treat or prevent disease syndromes relatedinadequate intake of L-carnitine or acetyl-L-carnitine, or to mutationsof mitochondrial DNA, changes in mitochondrial structure, anddeterioration of the body's ability to synthesize, conserve and absorbL-carnitine and acetyl-L-carnitine.

EXAMPLE 1

This example relates to the preparation of one liter of a stableacqueous solution containing, per milliliter, 45 mg L-carnitine and 45mg acetyl-L-carnitine. All procedures are carried out at roomtemperature unless otherwise indicated.

A solution is prepared by dissolving 45 grams of 1-carnitine in 500 mlwater. To this solution 45 grams of acetyl-1-carnitine are added anddissolved.

A second solution is made by dissolving 1 gram of methyl paraben in 400milliliters water. Dissolution can be hastened by warming the water to40 degrees centigrade and stirring constantly. The solutions are cooledto room temperature and water is added sufficient to bring the finalquantity to 1000 milliliters. The final solution is filtered to removerany and all bacteria, and like-sized microbes. This sterile solution isdispensed in sterile bottles.

This solution has a mildly acidic taste that enhances many food flavorsit is intended for oral administration or to be added to the diet ordrinking water of an individual animal at the rate of one milliliter perfifteen pounds body weight.

EXAMPLE 2

This example relates to preparation of one liter of sterile, neutral,stable aqueous solution containing, per milliliter, 16.7 mg carnitineand 16.7 mg acetyl-L-carnitine. All procedures are carried out at roomtemperature.

A solution is prepared by dissolving 16.7 grams of L-carnitine in 400milliliters of distilled, pyrogen free water. When it is dissolved 16.7grams acetyl-L-carnitine is added to the solution and is dissolved.

A second solution is made by dissolving 1 gram of methyl paraben in 400milliliters water. Dissolution can be hastened by warming the water to40 degrees centigrade and stirring constantly. The second solution ismixed with the first solution.

The pH of the mixed solutions is adjusted to neutrality withapproximately 2.95 grams NaOH. Sufficient quantity water is added tobring the final volume to 1000 milliliters and the solution is filteredthrough sterile equipment to remove bacteria and like-sized microbes. Itis then bottled in sterile rubber-stopped glass vials.

This solution is intended for subcutaneous, intramuscular or intravenousinjection at the rate of 1 ml per 15 pounds body weight. To provide theadded quality of being useful in animals unable to consume or retaininjested materials and in instances where rapidity of response totherapy may be critical for the life or well being of the patient.

EXAMPLE 3

This example relates to preparation of desiccated powder containingequal amounts of the L-carnitine and acetyl-L-carnitine.

The mixture is prepared by combining and uniformly mixing 50 mg of bothdesiccated L-carnitine and acetyl-L-carnitine in a low moistureatmosphere. An anticking agent may be blended into the mixture tofacilitate processing through a capsule filling machine. The choice ofanticaking agent must be compatible with state and federal pure food anddrug regulations. The powdered preparation is placed in gelatin capsulesof a size sufficient to contain 45 mg L-carnitine and 45 mgacetyl-L-carnitine to be swallowed by a 15 pound dog or the capsule maybe opened and the contents sprinkled onto or mixed with the patient'sfood.

EXAMPLE 4

This example relates to preparation of sterile desiccated powdercontaining equal amounts L-carnitine and acetyl-L-carnitine. The mixtureis prepared by combining and uniformly mixing, in a dry atmosphere, 50grams amounts of desiccated L-carnitine and acetyl-L-carnitine. Themixture is measured in 200 mg amounts into sterile, dry glass ampuleswhich are then sealed. Powder in vials is to be dissolved with sterilewater for intravenous use in cases of acute circulatory failure relatedto L-carnitine and acetyl-L-carnitine responsive cardiopathy ormitochondrial genome mutations where energy metabolism is compromised.

Consistent with the above, oral administration of preparations definedin Examples 1 and 3 were found to be useful in treating pet dogs withcardiomyopathy, skeletal muscle weakness, psychosis and epilepsy. Wherethese syndromes were actively manifested the preparation eliminated ormarkedly ameliorated symptoms. When the preparations were discontinuedor reduced in amount consumed syndromes recurred. Continuedsupplementation prevented syndrome development. The following examplesrelate to the effectiveness of the preparations of the invention.

EXAMPLE 5

A twelve year old male Weimaraner was treated for almost one year foranxiety and trembling. It all began when a minor earthquake one weekprevious to initial admittance to the hospital resulted in a fearfulchange in the dog's behavior. Normally placid, following the quake hehad trembled uncontrollably when put in his owner's backyard. He wasreluctant to enter the hospital and tried to avoid being handled.However, he was not aggressive nor did he show any tendency to bite fromfear. Cranial nerve function was normal and clinical examinationrevealed no physical ailments. It was assumed the dog had a form ofanxiety and he was treated with 25 mg of the mood-altering antipsychosisdrug doxepin HCl orally once daily. This satisfactorily diminishedsymptoms for several weeks after which anxiety gradually returned. Sixmonths after starting treatment he was as troubled as when firstpresented. Medication was changed to 20 mg of another antipsychosis drugfluoxetine HCl orally once daily. Again, anxiety subsided for a fewweeks but in time returned and steadily increased in severity. In spiteof daily behavior-modifying therapy his mental condition deteriorated tothe extent that he voluntarily confined himself and hid behind a couchin one room of the house. Trembling had become violent when he was takenout of doors and he was unable to go on short walks. His food bowlfrightened him and he refused to eat unless fed from the owner's hand.

When again brought to the hospital after almost eleven months of therapywith antipsychosis drugs he was very psychotic. His owner had to dragthe panicking dog into the waiting room where he trembled and cowardunder the owner's chair. Clinical examination was much as it wasinitially. Euthanasia was considered but the owners opted for increasingfluoxetine HCI dosage to 40 mg daily. This gave little relief After twodays it was decided to discontinue treatment of the dog withantipsychosis drugs and to investigate a novel therapy. The decision waspredicated upon the inventor's personal experience. Having endureddepression nightly for more than two decades. The first time he consumedone 500 mg capsules of acetyl-L-carnitine in a "pop culture" effort toimprove his memory. Depression ceased| And remained so as long as Alcarwas consumed daily. It was thought, there may be a physiologicsimilarity between depression in humans and psychosis in dogs, the dog'sowners agreed to add mg per pound body weight acetyl-L-carnitine orallymorning and night to his treatment regimen for one week. The dog'spsychosis began to diminish within two days. By the end of the week heno longer hid in the house, would eat from his food bowl, and tremblingwhen he went outside was much less severe. Acetyl-L-carnitine therapywas continued but fluoxetine HCI dosage was reduced to 20 mg orally oncedaily. His fearfulness continued to diminish and he began to go on shortwalks. Twenty-one days later symptoms were so minimal that fluoxetineHCI was discontinued. Within a week his behavior and activity level wereas normal as they had been three years previously. However, that day,while on a moderately long walk he suddenly collapsed, temporarilybecame unconscious and, unable to rise or walk, was carried home. Theowner commented that on the previous day's walk a similar but lesssevere episode had taken place.

When examined at the hospital he was conscious but very depressed withno sign of anxiety. His pulse was weak, 200 beats per minute, andcapillary refill time was four seconds. An electrocardiogram (ECG)tracing showed no arrhythmia but the T-wave was augmented with negativepolarity. Because of symptoms: syncope, exercise intolerance, weakpulse, tachycardia, and prolonged capillary refill time the dog wasdiagnosed as suffering from cardiac failure. Sustained-release 500 mgprocainamide orally morning and night was added to theacetyl-L-carnitine regimen. The following day, an ECG showedimprovement. Amplitude of the T-wave was less but polarity was stillnegative. His demeanor was brighter and he was responsive to owner andsurroundings. Within three days he could again walk for short distanceswithout signs of distress. However, his exercise tolerance wassub-normal. It was decided to continue giving him the procainamide, forit seemed to have helped cardiac function, but replaceacetyl-L-carnitine with L-carnitine, 5 mg per pound body weight orallymorning and night, to see if it might further improve his level ofphysical activity. Following seven days of L-carnitine supplement, hislevel of physical activity was again normal and he was going fortwo-mile long walks. In an attempt to clarify whether the dog's activitylevel had returned to normal because of carnitine and its metaboliceffects on heart muscle or the procainamide and its effect on cardiacimpulse conduction, the latter was phased out through the ensuing week.During that time he continued to walk and run normally with no evidenceof cardiac insufficiency. This indicated disturbed metabolism ofmyocardial cells must have caused the circulatory failure for the dog'slevel of activity improved most when he was given L-carnitine and itremained normal with deletion of procainamide. Daily treatment only withL-carnitine was continued. Then after 17 days withoutacetyl-L-carnitine, the owner called to report the dog's physicalactivity was normal but psychosis had returned. It appeared, on onehand, that acetyl-L-carnitine had improved the dog's psychic state butcardiac malfunction developed once his activity level increased. On theother hand, L-carnitine had corrected the circulatory failure withoutbenefiting the psychosis. In an effort to correct the resurgingpsychotic state while preventing recurrence of heart failureacetyl-L-carnitine and L-carnitine were given to the dog. To evaluatetheir compatibility the two nutrients were mixed together as powders inequal parts as a dietary supplement to be added as a powder to the dog'sfood. Dosage was mg per pound body weight daily. While on thecombination anxiety symptoms disappeared within five days and no furtherheart failure signs developed. The nutrient combination was continuedand the dog behaved normally, running and playing, with no signs of fearor anxiety for two months after which time he was boarded at thehospital. While at the hospital he was closely observed, and judged tobehave and function as normally as when he was three years younger.

EXAMPLE 6

The second case, an eight year old spayed mixed-breed shepherd, waspresented with history of weakness of rear legs and back of severalmonths duration. She spent most of her time lying down, even wheneating. After lying she was slow to stand and moved stiffly as if weakor in pain, she could not jump as she had in the past, and after briefexercise she would be reluctant to move and panted excessively. Shewinced in pain from pressure on the gluteal region. Spinal radiographsshowed moderate lesions of spondyloarthopathy only at the lumbo-sacraljunction. There appeared to be atrophy of masticatory and longissimusmuscles, for bones of head and spinal processes were prominent. Bloodcount and serum chemistries were all within normal parameters. Indirectfluorescent-antibody tests with the dog's serum obtained on day onereacted against rat sciatic nerve tissue were negative, for antibodiesagainst nerve tissue skeletal muscle tests showed a weak nonspecificresponse to muscle fibers but there was no reaction to connective tissueor vascular elements. A Hep-2 test for serum antinuclear antibodies wasnegative. Biopsy of longissimus muscle on day two at the level of lumbarvertebrae L2 and 3 revealed about half of muscle mass atrophied orreplaced by fat. The possibility of immune-mediated myositis promptedtherapeutic testing with prednisone and azathioprine for ten days,beginning on day seven. During the course of treatment there was aslight improvement in the dog's ability to move about but the responsewas considered inconclusive. Based on poor clinical response to immunesuppression and negative indirect fluorescent antibody tests forantibodies to skeletal muscle it was concluded her malady probably wasother than immune-mediated myositis. Longissimus muscle biopsy specimensbecame available on day thirteen. They substantiated the conclusion thatthe dog's muscle weakness was not an immune mediated myopathy for therewas no inflammatory reaction in the muscle. Instead, there was bothmuscle fiber atrophy and metaplasia of satellite cells to lipocytes.There was no evidence of ragged red fibers as seen in humans with MELAS.

On day twenty-four, L-carnitine mg, per pound body weight orally twicedaily in her food was prescribed. After three weeks of this treatment,the owner reported the dog was much stronger, now being able to jumpinto a pickup truck. She could walk and run about normally withoutapparent pain or panting and she could get to her feet quickly afterlying down and no longer lay down to eat. The dog's condition continuedto be satisfactory while receiving L-carnitine daily. To compareeffectiveness and possible biochemical interchange of two nutrients,acetyl-L-carnitine was substituted for L-carnitine on day one-hundred.Sixteen days later the owner reported the dog's weakness, panting, andpain on palpation of gluteal region had returned. It was concludedL-carnitine but not acetyl-L-carnitine effectively relieved the dog'ssymptoms. To investigate compatibility and effectiveness of the combinednutrients L-carnitine and acetyl-L-carnitine were mixed in equal amountsand dispensed to be added to the dog's food, mg per pound body weightonce daily. Following seven days of this therapy the owner telephoned tosay the dog's activity and demeanor were again normal, the same as theyhad been when the dog was receiving L-carnitine and beforeacetyl-L-carnitine alone was given.

This example demonstrates beneficial effects of the invention when usedto treat a dog with a previously undescribed skeletal myopathy.L-carnitine alone produced progressive improvement over a three weekperiod before reaching a stable plateau. When acetyl-L-carnitine wassubstituted for carnitine the dog's previous clinical condition wasreinstated in less than three weeks indicating Alcar was ineffective.However, the fact the invention elevated symptoms of muscle weakness andpain after one week of therapy indicates synergism between the twometabolic cofactors.

EXAMPLE 7

The third dog, a cardiac case when presented was clinically typical ofother large dogs seen in practice that have a cardiac arrhythmia,usually ventricular tachycardia, often with unsatisfactory response, tomedical management. This case illustrates, that in addition to cardiacdisease, skeletal muscle weakness and epileptiform seizures can bemanifest simultaneous in one dog and all respond to an oral supplementof combined L-carnitine and acetyl-L-carnitine.

The eight year old spayed Siberian Husky, when presented had a historyof episodes of grand mall seizures, muscle weakness, and hypothyroidism,she was receiving levothyroxin Na daily. Initially, seizures occurredevery few months when they began five years previously. No medical basiswas found for the convulsions and there was no evidence of other centralnervous dysfunction. When seizure frequency became more than one a monththe owner sought medical assistance and the dog was treated with 25% KBrsolution, 1 ml per 15 pounds body weight, orally once daily whichcontrolled seizures.

Muscle weakness had been a progressive condition for three years. Otherthan an inconclusive superficial clinical examination for lameness noeffort had been made to ascertain cause of the weakness. In her dailylife prior to admittance she had become so weak she had to be supportedwith a sling under her belly whenever she walked more than twenty yards.

The day before admittance to the hospital the dog seemed to the owner tohave a seizure. He considered the episode to be an atypical convulsion.Symptoms were described as disorientation, weakness, and collapse. Whenpresented at the hospital the dog was unable to stand and walk. She hadto be carried from the car into the hospital. On examination her pulsewas weak and irregular. Her creatinine phosphokinase was four timeshigher than normal indicating probable heart muscle injury. An ECGshowed long periods of ventricular tachycardia, a severe often fatalform of heart arrhythmia, with intermittent periods in which rhythm wasnormal but R wave magnitude was diminished. The dog's immediate problemwas diagnosed as cardiac failure and the previous day's episode, whichthe owner witnessed, was considered to be syncope caused by an episodeof ventricular tachycardia. The dog was treated with lidocaine andpropanalol intravenously, with this standard treatment it was impossibleto convert the arrhythmia. As a last resort she was treated orally with500 mg sustained release procainamide and, because of beneficial cardiacresponse to combined L-carnitine and acetyl-L-carnitine with a previouscase the combination was administered orally mg per pound body weight.The same treatment was administered that evening and the followingmorning. The ECG after twenty-four hours of treatment no longer showedevidence of ventricular tachycardia but was in other respects similar tothe previous day. She was alert and responsive, still weak but asfunctional as she had been before the syncope episode. She was eatingwell so the L-carnitine, acetyl-L-carnitine combination was mixed in herfood and continued morning and night for one week at which time her ECGwas nearly normal and the procainamide was stopped and the L-carnitineand acetyl-L-carnitine combination was supplemented once daily. Sheshowed no further heart related symptoms.

Just as the dog's cardiac function responded to the supplement hermuscle weakness also improved. Four weeks after commencing treatmentwith L-carnitine and acetyl-L-carnitine the owner reported the dog wasmore active than she had been in several years, now free of all supportshe was able to run rapidly and happily about the house and go for longwalks. The ECG, at that time, day twenty-eight was normal. In additionto heart and muscle function improvement, her nervous system hadimproved. Because of her good spirits it was decided to phase outseizure controlling medications. Three months after stopping all seizurecontrol medication, her health continued to be good. She was veryactive, her haircoat, which had been rough and ragged, had becomeluxurious and she had one mild seizure once each month since treatmentwith L-carnitine and acetyl-L-carnitine began.

Numerous modifactions on variations in practice of the invention in itsseveral aspects as above described are expected to occur suchlimitations as are set out in appended claims should be placed there on.

What is claimed is:
 1. A method of treating a domesticated mammal orhuman in need of treatment, comprising the step of (a) administering toa domesticated mammal or human having a condition or conditions, relatedto dysfunctional energy metabolism that do not quickly or substantiallypermanently respond to L-carnitine or acetyl-L-carnitine alone, aneffective amount of a preparation containing both L-carnitine andacetyl-L-carnitine, to substantially permanently alleviate the symptomsof or substantially cure the condition or conditions related todysfunctional energy metabolism.
 2. A method as recited in claim 1wherein step (a) is practiced by administering daily a preparationcontaining at least about 2 milligrams each of both L-carnitine andacetyl-L-carnitine per pound of body weight of the domesticated mammalor human being treated.
 3. A method as recited in claim 1 wherein step(a) is practiced so as to administer a preparation containing about 5milligrams each of both L-carnitine and acetyl-L-carnitine per pound ofbody weight of the domesticated mammal or human being treated.
 4. Amethod as recited in claim 1 wherein step (a) is practiced by adding thepreparation of both L-carnitine and acetyl-L-carnitine to a dog's foodso that the preparation is taken orally.
 5. A method as recited in claim1 wherein step (a) is practiced by administering the preparation of bothL-carnitine and acetyl-L-carnitine parenterally.
 6. A method as recitedin claim 1 wherein step (a) is practiced with a ratio of L-carnitine toacetyl-L-carnitine of from about 1 to 2 to about 2 to
 1. 7. A method asrecited in claim 1 wherein step (a) is practiced by administering apreparation with approximately equal amounts of L-carnitine andacetyl-L-carnitine.
 8. A method as recited in claim 1 wherein step (a)is also practiced by mixing preservative, stabilizing, coloring, orflavoring agents, or combinations thereof, to the preparation before itis administered, and by administering at least 2 milligrams per pound ofbody weight of the human or domesticated mammal being treated.
 9. Apharmacological preparation for treating dysfunctional energy metabolismconditions, comprising a combined amount of both L-carnitine andacetyl-L-carnitine pharmacologically effective for treatingdysfunctional energy metabolism conditions wherein the ratio ofL-carnitine to acetyl-L-carnitine is from about 1 to 2 to about 2 to 1.10. A pharmacological preparation as recited in claim 9 furthercomprising preservative, stabilizing, coloring, or flavoring agents, orcombinations thereof.
 11. A pharmacological preparation as recited inclaim 9 wherein the preparation also contains an anti-caking agent andis in the form of a gelatin capsule for oral consumption.
 12. Apharmacological preparation as recited in claim 9 wherein the effectiveingredients of the preparation consist essential of L-carnitine andacetyl-L-carnitine.
 13. A method of preventing dysfunctional energymetabolic conditions by practicing the step of: (a) administering to ahuman or domesticated mammal a prophylactic amount of a pharmacologicalpreparation containing both L-carnitine and acetyl-L-carnitine effectiveto substantially prevent dysfunctional energy metabolic conditions. 14.A method as recited in claim 13 wherein step (a) is practiced byadministering the preparation orally.
 15. A method as recited in claim14 wherein step (a) is further practiced by daily administering apreparation containing at least about 2 milligrams each of bothL-carnitine and acetyl-L-carnitine per pound of body weight of the humanor domesticated mammal being treated.
 16. A method as recited in claim14 wherein step (a) is further practiced using a ratio of L-carnitine toacetyl-L-carnitine from about 1 to 2 to about 2 to 1 in the preparation.17. A method as recited in claim 14 wherein step (a) is furtherpracticed using a preparation which also contains an anti-caking agentand is in the form of a gelatin capsule.
 18. A method as recited inclaim 14 wherein step (a) is practiced by administering the preparationin the form of a stable liquid aqueous solution containing, permilliliter volume, from 0.1 to 400 mg each of both L-carnitine andacetyl-L-carnitine.
 19. A method as recited in claim 11 wherein step (a)is practiced using a formulation where the effective ingredients consistessentially of L-carnitine and acetyl-L-carnitine.
 20. A method asrecited in claim 1 wherein step (a) is practiced using a preparationwith a ratio of L-carnitine to acetyl-L-carnitine of from about 1 to 40to about 40 to 1, and a domesticated animal is treated.